Form

COVID‐19 PANDEMIC ‐ PATIENT SCREENING FORM

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Patient's First Name

Last

Has ANYONE in your immediate family had a cough, fever over 100, difficulty breathing, or flu-like symptoms in the last 10 days?

Are you/they having shortness of breath or other difficulties breathing?

Do you/they have a cough?

Any other flu-like symptoms, such as gastrointestinal upset, headache, fever or fatigue?

Have you/they experienced recent loss of taste or smell?

Are you/they in contact with any confirmed COVID-19 positive patients?
Patients who are well but who have a sick family member at home with a fever or COVID-19 should postpone any elective treatment.

Has ANYONE in your immediate family been caring for a patient diagnosed with a fever or Covid-19?

Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?

*Positive responses to any of these would indicate rescheduling treatment for a minimum of 7 days/negative covid test.

For testing, see the list of State and Territorial Health Department Websites for your specific area's information.

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